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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> p APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE"- <br /> Application is hereby made to carry on business in theJurisdictional area of the San Joaquin Local Health District <br /> ,r Business Name (DBA) Address__/]-�' /17y�t 1=' ra rr�r/ <br /> a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers r �_ <br /> aBusiness Telephone No. - Emergency Telephone No. <br /> Contractor Licence No. ,�4xs­_)-.74 <br /> L Applicants Name (Print) EA. vii' z_�. 4(J"p Title 6eAfZ�. Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C I <br /> For July 1,-. June 30, 19- - -Disposal Sites. - -- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> i 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 " �Y <br /> No, of Vehicles Stored _ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location } + Test Date/Time <br /> 4. K SANITATION PERMIT <br /> Job Address/Location 1rQ? <br /> Owner �T7� Az <br /> DG�/a? .!/7^t9 _ Address <br /> LPSEPTIC TANK E] CESSPOOL W LEACHING FIELD q�,SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY R NEW 1 ❑ REPAIR ? ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' f <br /> Type Construction Disposal Site <br /> No. of Units r Equipment Storage/Cleaning Location(s) t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f <br /> Operator Name Where Certified <br /> Plant Location = i" 7 t i !~` =' <br /> Plant Capacity No!Units Served ) <br /> 7. ❑ LAUNDRY For July 1,•-June 30,"19- <br /> .SIZE: <br /> 0;"19.SIZE: ❑ Less Than 1,000 Sq. Fl., ❑ More Than 1,000 Sq.-Ft. } , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. } a <br /> Home Omer orlicensed agent's sig nature eertl cc..i tollewinr�:�f•certifyth:tiziheperfor-nanceoftheworktorwhichthis Permit isissued,lShall not employ any person <br /> in such manner as to become Subject to wor'rtnasl's ccingansativ7 jays Bf Cafift7nli�.'' <br /> Contmetoes hiring or sub-contracting elgriature ,,sh$ fcno-09; 1certify that in the performance of the work for which this permit is issued,t shall <br /> rnploy persons subject to workman's compensation taws of Calit&nia.- <br /> .j it <br /> j 1 hereby certify that I,have prepared this application and that the work will be done in accordance with San Joaquin County <br /> $ ordinances, state laws, and rules and regulations of,the•S nn._Jbaq in Local Health District. <br /> -APPLICANT'S SIGNATURE X <br /> FOR DEPA'RTMENT'USE ONLY 1 ' <br /> Fee Is Due: 131ANNUALLY y ❑ PER UNIT El❑ PER SITE Q EACH 40 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION/ � <br /> BILLWG,. REMITTANCE $ AMOUNT DUE CHECKED \ <br /> t DATEi,,, DATE REMITTED AMOUNT ` .+ <br /> 'rL - <br /> ve <br /> F FEE y ` 11 <br /> LESS t { J <br /> PRORATION <br /> PLUS `rl <br /> PENALTY <br /> OTHER <br /> v <br /> OTHER <br /> Received by Date Receipt No: Permit No. Issuance De.:' Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1fi01 E.HAZELTON O.Sox 2009 STOCKTON,CA 95201 <br />